Story 1: Ebola Spreading with Reproductive Number, R0 or R Naught Exceeding 1 — Obama Sends 3,000 U.S. Troops to Liberia — worst-case hypothetical scenario, should the outbreak continue with recent trends, the case burden could gain an additional 77,181 to 277,124 cases by the end of 2014! — Videos

Obama pledges military personnel to nations struck by Ebola

Battling Ebola: U.S. to send 3,000 troops to West Africa

President Obama To Deploy 3,000 U.S. Troops To Fight Ebola In Africa NEWS 2014

Obama Sending 3000 U.S. Soldiers To Western Africa To Help With Ebola Crisis

Obama to Launch Enhanced U.S. Ebola Response

Inside an Ebola Hospital in West Africa

Ebola Hunters & Disease Detectors in Africa

Obama Sending 3000 Troops To Africa To Combat The Ebola Virus?

EBOLA: State Department Orders 160,000 Hazmat Suits

Week 1 Video 5: Reproductive Number

Week 1 Video 6: Epidemic Curve

Ebola – What You’re Not Being Told

Scientist Working on Gov’t Ebola Drug Joked About Culling Population with GMO Virus

Foreshadowing Ebola In The Movies??

Contagion (2011) Official Exclusive 1080p HD Trailer

The world’s deadliest virus Ebola Plague Fighters Nova Documentary

Ebola mathematics stark warning of disease’s spread

The Ebola epidemic in Africa has continued to expand since I last wroteabout it, and as of a week ago, has accounted for more than 4,200 cases and 2,200 deaths in five countries: Guinea, Liberia, Nigeria, Senegal and Sierra Leone. That is extraordinary: Since the virus was discovered, no Ebola outbreak’s toll has risen above several hundred cases. This now truly is a type of epidemic that the world has never seen before. In light of that, several articles were published recently that are very worth reading.

The most arresting is a piece published last week in the journal Eurosurveillance, which is the peer-reviewed publication of the European Centre for Disease Prevention and Control (the EU’s Stockholm-based version of the US CDC). The piece is an attempt to assess mathematically how the epidemic is growing, by using case reports to determine the “reproductive number.” (Note for non-epidemiology geeks: The basic reproductive number — usually shorted to R0 or “R-nought” — expresses how many cases of disease are likely to be caused by any one infected person. An R0 of less than 1 means an outbreak will die out; an R0 of more than 1 means an outbreak can be expected to increase. If you saw the movie Contagion, this is what Kate Winslet stood up and wrote on a whiteboard early in the film.)

The Eurosurveillance paper, by two researchers from the University of Tokyo and Arizona State University, attempts to derive what the reproductive rate has been in Guinea, Liberia and Sierra Leone. (Note for actual epidemiology geeks: The calculation is for the effective reproductive number, pegged to a point in time, hence actually Rt.) They come up with an R of at least 1, and in some cases 2; that is, at certain points, sick persons have caused disease in two others.

You can see how that could quickly get out of hand, and in fact, that is what the researchers predict. Here is their stop-you-in-your-tracks assessment:

In a worst-case hypothetical scenario, should the outbreak continue with recent trends, the case burden could gain an additional 77,181 to 277,124 cases by the end of 2014.

That is a jaw-dropping number.

The epidemic curves of the Ebola epidemic; look especially at the line for Liberia.

Nishiura and Chowell

What should we do with information like this? At the end of last week, two public health experts published warnings that we need to act urgently in response.

First, Dr. Richard E. Besser: He is now the chief health editor of ABC News, but earlier was acting director of the US CDC, including during the 2009-10 pandemic of H1N1 flu; so, someone who understands what it takes to stand up a public-health response to an epidemic. In his piece in the Washington Post, “The world yawns as Ebola takes hold in West Africa,” he says bluntly: “I don’t think the world is getting the message.”

He goes on:

“The level of response to the Ebola outbreak is totally inadequate. At the CDC, we learned that a military-style response during a major health crisis saves lives…

“We need to establish large field hospitals staffed by Americans to treat the sick. We need to implement infection-control practices to save the lives of health-care providers. We need to staff burial teams to curb disease transmission at funerals. We need to implement systems to detect new flare-ups that can be quickly extinguished. A few thousand U.S. troops could provide the support that is so desperately needed.”

Aid ought to be provided on humanitarian grounds alone, he argues – but if that isn’t adequate rationale, he adds that aid offered now could protect us in the West from the non-medical effects of Ebola’s continuing to spread: “Epidemics destabilise governments, and many governments in West Africa have a very short history of stability. US aid would improve global security.”

Should we really be concerned about the global effect of this Ebola epidemic? In the New York Times, Dr. Michael T. Osterholm of the University of Minnesota* – an epidemiologist and federal advisor famous forinadvertently predicting the 2001 anthrax attacks – says yes, we should. In “What We’re Afraid to Say About Ebola,” he warns: “The Ebola epidemic in West Africa has the potential to alter history as much as any plague has ever done.”

He goes on:

“There are two possible future chapters to this story that should keep us up at night.

“The first possibility is that the Ebola virus spreads from West Africa to megacities in other regions of the developing world. This outbreak is very different from the 19 that have occurred in Africa over the past 40 years. It is much easier to control Ebola infections in isolated villages. But there has been a 300 percent increase in Africa’s population over the last four decades, much of it in large city slums…

“The second possibility is one that virologists are loath to discuss openly but are definitely considering in private: that an Ebola virus could mutate to become transmissible through the air… viruses like Ebola are notoriously sloppy in replicating, meaning the virus entering one person may be genetically different from the virus entering the next. The current Ebola virus’s hyper-evolution is unprecedented; there has been more human-to-human transmission in the past four months than most likely occurred in the last 500 to 1,000 years. Each new infection represents trillions of throws of the genetic dice.”

Like Besser, Osterholm says that the speed, size and organisation of the response that is needed demands a governmental investment, but he looks beyond the US government alone:

“We need someone to take over the position of “command and control.” The United Nations is the only international organisation that can direct the immense amount of medical, public health and humanitarian aid that must come from many different countries and nongovernmental groups to smother this epidemic. Thus far it has played at best a collaborating role, and with everyone in charge, no one is in charge.

“A Security Council resolution could give the United Nations total responsibility for controlling the outbreak, while respecting West African nations’ sovereignty as much as possible. The United Nations could, for instance, secure aircraft and landing rights…

“The United Nations should provide whatever number of beds are needed; the World Health Organization has recommended 1,500, but we may need thousands more. It should also coordinate the recruitment and training around the world of medical and nursing staff, in particular by bringing in local residents who have survived Ebola, and are no longer at risk of infection. Many countries are pledging medical resources, but donations will not result in an effective treatment system if no single group is responsible for coordinating them.”

I’ve spent enough time around public health people, in the US and in the field, to understand that they prefer to express themselves conservatively. So when they indulge in apocalyptic language, it is unusual, and notable.

When one of the most senior disease detectives in the US begins talking about “plague,” knowing how emotive that word can be, and another suggests calling out the military, it is time to start paying attention.

As of 10 September 2014, the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC) reported a total of 4,846 suspected cases and 2,375 deaths (2,898 cases and 1,386 deaths being laboratory confirmed).[2][3] Many experts believe that the official numbers substantially understate the size of the outbreak because of families’ widespread reluctance to report cases.[7] On 28 August, the WHO reported an overall case fatality rate (CFR) estimate of 52%, considerably lower than an average of the rates reported from previous outbreaks. However, difficulties in collecting information and the methodology used in compiling it may be resulting in an artificially low number.[8] A more accurate method that observed patient outcomes in Sierra Leone found a CFR of 77%.[9]

Affected countries have encountered many difficulties in their attempt to control the spread of this Ebola epidemic, the first that West African nations have experienced. In some areas, people have become suspicious of both the government and hospitals; some hospitals have been attacked by angry protestors who believe that the disease is a hoax or that the hospitals are responsible for the disease. Many of the areas that have been infected are areas of extreme poverty without even running water or soap to help control the spread of disease.[10] Other factors include belief in traditional folk remedies, and cultural practices that predispose to physical contact with the deceased, especially death customs such as washing the body of the deceased.[11][12][13] Some hospitals lack basic supplies and are understaffed, which has increased the likelihood of staff catching the virus themselves. In August, the WHO reported that ten percent of the dead have been health care workers.[14]

By the end of August, the WHO reported that the loss of so many health workers was making it difficult for them to provide sufficient numbers of foreign medical staff.[15] By September 2014, Médecins Sans Frontières, the largest NGO working in the affected regions, had grown increasingly critical of the international response. Speaking on 3 September, the international president spoke out concerning the lack of assistance from the United Nations member countries saying, “Six months into the worst Ebola epidemic in history, the world is losing the battle to contain it”.[16] A United Nations spokesperson has stated “they could stop the Ebola outbreak in west Africa in 6 to 9 months, but only if a ‘massive’ global response is implemented.”[17] The Director-General of the WHO, Margaret Chan, called the outbreak “the largest, most complex and most severe we’ve ever seen” and said that it “is racing ahead of control efforts”.[17] On 12 September Chan stated, “In the three hardest hit countries, Guinea, Liberia and Sierra Leone, the number of new cases is moving far faster than the capacity to manage them in the Ebola-specific treatment centers. Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia.”[18]

Development of the outbreak

Initial outbreak in Guinea

Researchers believe that the first human case of the Ebola virus disease leading to the 2014 outbreak was a 2-year-old boy who died 6 December 2013 in the village of Meliandou, Guéckédou Prefecture, Guinea. His mother, sister and grandmother then became ill with symptoms consistent with Ebola infection and died. People infected by those victims spread the disease to other villages.[1][19]

On 19 March, the Guinean Ministry of Health acknowledged a local outbreak of an undetermined viral hemorrhagic fever; the outbreak, ongoing since February, had sickened at least 35 people and killed 23. Ebola was suspected,[20] and on 25 March, the World Health Organization (WHO) reported that the Ministry of Health of Guinea had reported an outbreak of Ebola virus disease in four southeastern districts, with suspected cases in the neighbouring countries of Liberia and Sierra Leone being investigated. In Guinea, a total of 86 suspected cases, including 59 deaths (case fatality ratio: 68.5%), had been reported as of 24 March.[21]

On 31 March, the U.S. CDC sent a five-person team to assist Guinea Ministry of Health and WHO to lead an international response to the Ebola outbreak. On that date, the WHO reported 112 suspected and confirmed cases including 70 deaths. Two cases were reported from Liberia of people who had recently traveled to Guinea, and suspected cases in Liberia and Sierra Leone were being investigated.[21] On 30 April, Guinea’s Ministry of Health reported 221 suspected and confirmed cases including 146 deaths. The cases included 25 health care workers with 16 deaths. By late May, the outbreak had spread to Conakry, Guinea’s capital, a city of about two million inhabitants.[21] On 28 May, the total cases reported had reached 281 with 186 deaths.[21]

Subsequent spread

Situation in Guinea, Liberia, and Sierra Leone as of 4 September 2014.[22]

Sierra Leone

The outbreak next spread to Sierra Leone and progressed rapidly. The first cases were reported on 25 May in the Kailahun District, near the border with Guéckédou in Guinea.[28] By 20 June, there were 158 suspected cases, mainly in Kailahun and the adjacent district of Kenema, but also in the Kambia, Port Loko, and Western districts in the north west of the country.[29] By 17 July, the total number of suspected cases in the country stood at 442, and had overtaken those in Guinea and Liberia.[30] By 20 July, cases of the disease had additionally been reported in the Bo District;[31] the first case in Freetown, Sierra Leone’s capital, was reported in late July.[32][33]

Nigeria

The first case in Nigeria was reported by the WHO on 25 July:[34] Patrick Sawyer, who flew from Liberia to Nigeria after exposure to the virus, and died at Lagos soon after arrival.[35] As part of the containment efforts, 353 possible contacts were monitored in Lagos and 451 in Port Harcourt. As at 16 September, the outbreak appears to have stabilised with 22 confirmed cases and 8 deaths, no new cases having been confirmed for 2 weeks.[36]

Senegal

On 29 August, the Senegalese Health minister, Awa Marie Coll Seck, announced the first case of Ebola in Senegal. [37][38] This case has subsequently recovered, but 67 possible contacts are being monitored in order to prevent further spread of the disease.[36]

Virology

Ebola virus disease is caused by four of five viruses classified in the genus Ebolavirus, family Filoviridae, order Mononegavirales. The four disease-causing viruses are Bundibugyo virus, Sudan virus, Taï Forest virus, and one called simply, Ebola virus (formerly and often still called the Zaire Ebola virus). Ebola virus is the most dangerous of the known Ebola disease-causing viruses, as well as being responsible for the largest number of outbreaks.[39]The strain of virus affecting people in the current outbreak is a member of the Ebolus virus (Zaire) lineage.[40] An article published in the New England Journal of Medicine on-line in April 2014 asserted that while the Ebola virus in Guinea shared 97% of its genetic code with the Zaïre lineage, it was of a different clade than the strains from outbreaks in the Democratic Republic of Congo and Gabon, and constituted a new strain indigenous to Guinea, and was not imported from Central Africa to West Africa.[19] This result, however was contradicted by two subsequent reports.

The first of these reports reached the conclusion that the outbreak “is likely caused by a Zaire ebolavirus (Ebola virus) lineage that has spread from Central Africa into Guinea and West Africa in recent decades, and does not represent the emergence of a divergent and endemic virus.”[41] A second report published in June 2014 also supports the latter view, determining that it was “extremely unlikely that this virus falls outside the genetic diversity of the Zaïre lineage” and that their analysis “unambiguously supports Guinea 2014 EBOV as a member of the Zaïre lineage.”[40]

Among 78 patients diagnosed with the Ebola virus during the first 24 days of the outbreak in Sierra Leone, 300 genetic changes were found that make the 2014 Ebola virus distinct from previous outbreaks. It is still unclear whether these differences are related to the severity of the current outbreak.[9][42]

Médecins Sans Frontières described the situation as being “totally out of control” in late June. Urging the world to offer aid to the affected regions, the Director-General said, “Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible.”[44]

Disease reports accelerated in August with 40% of the total cases reported in a period of only three weeks. The WHO stated that the acceleration could see the number of cases reported exceed 20,000.[47][48]

Speaking at a United Nations (UN) briefing on 2 September, Joanne Liu, international president of Médecins Sans Frontières, criticized the lack of assistance from UN member countries.

“Six months into the worst Ebola epidemic in history, the world is losing the battle to contain it. In West Africa, cases and deaths continue to surge. Riots are breaking out. Isolation centers are overwhelmed. Health workers on the front lines are becoming infected and are dying in shocking numbers. Others have fled in fear, leaving people without care for even the most common illnesses. Entire health systems have crumbled. Ebola treatment centers are reduced to places where people go to die alone, where little more than palliative care is offered. It is impossible to keep up with the sheer number of infected people pouring into facilities. In Sierra Leone, infectious bodies are rotting in the streets.”[14]

Speaking in September after visiting Liberia, Sierra Leone, and Guinea, Tom Frieden, director of the U.S. CDC, said, “There is a window of opportunity to tamp this down, but that window is closing … we need action now to scale up the response.”[49] On 16 September, United States President Barack Obama announced that the U.S. military will take the lead in overseeing the response to the epidemic.[50]

Travel restrictions

On 8 August, a cordon sanitaire, a disease fighting practice that forcibly isolates affected regions, was established in the triangular area where Guinea, Liberia, and Sierra Leone are separated only by porous borders and where 70 percent of the known cases had been found.[7] By September, the closure of borders had caused a collapse of cross-border trade and was having a devastating effect on the economies of the involved countries. A United Nations spokesperson reported that the price of some food staples had increased by as much as 150% and warned that if they continue to rise widespread food shortages can be expected.

On 2 September, WHO Director-General Margaret Chan advised against travel restrictions saying that they are not justified and that they are preventing medical experts from entering the affected areas and “marginalizing the affected population and potentially worsening [the crisis]”. UN officials working on the ground have also criticized the travel restrictions saying the solution is “not in travel restrictions but in ensuring that effective preventive and curative health measures are put in place.” [14] Médecins Sans Frontières, also speaking out against the closure of international borders, called it “another layer of collective irresponsibility”: “The international community must ensure that those who try to contain the outbreak can enter and leave the affected countries if need be. A functional system of medical evacuation has to be set up urgently.”[16]

Complications

Difficulties faced in attempting to contain the outbreak include the outbreak’s multiple locations across country borders,[44]Dr Peter Piot, the scientist who co-discovered the Ebola virus, has stated that the present outbreak is not following its usual linear patterns as mapped out in previous outbreaks. This time the virus is “hopping” all over the West African epidemic region.[51] Furthermore, past epidemics have occurred in remote regions, but this outbreak has spread to large urban areas which has increased the number of contacts an infected person may have and has also made transmission harder to track and break. [15][15]

Adequate equipment has not been provided for medical personnel,[52] with even a lack of soap and water for hand-washing and disinfection.[53] Containment efforts are further hindered because there is reluctance among country people to recognize the danger of infection related to person-to-person spread of disease, such as burial practices which include washing of the body of one that has died.[11][12][13][32] A condition of dire poverty exists in many of the areas that have experienced a high incidence of infections. According to the director of the NGOPlan International in Guinea, “The poor living conditions and lack of water and sanitation in most districts of Conakry pose a serious risk that the epidemic escalates into a crisis. People do not think to wash their hands when they do not have enough water to drink.”[10]

Denial in some affected countries has often made containment efforts difficult.[54] Language barriers and the appearance of medical teams in protective suits has sometimes exaggerated fears of the virus.[55] There are reports that some people believe that the disease is caused by sorcery and that doctors are killing patients.[56] In late July, the former Liberian health minister, Peter Coleman, stated that “people don’t seem to believe anything the government now says.”[57] Acting on a rumor that the virus was invented to conceal “cannibalistic rituals” (due to medical workers preventing families from viewing the dead), demonstrations were staged outside of the main hospital treating Ebola patients in Kenema, Sierra Leone. The demonstrations were broken up by the police and resulted in the need to use armed guards at the hospital.[58] In Liberia, a mob attacked an Ebola isolation centre stealing equipment and “freeing” patients while shouting “There’s no Ebola”.[59] Red Cross staff was forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives.[60]

Contact tracing is an essential method to tamp down the spread of the disease. It involves finding everyone who had close contact with an Ebola case, and track them for 21 days. However this requires careful record keeping by properly trained & equipped staff.[61] WHO Assistant Director-General for Global Health Security, Keiji Fukuda, said on 3 September “We don’t have enough health workers, doctors, nurses, drivers, and contact tracers to handle the increasing number of cases.”[62]

Healthcare providers

Healthcare providers caring for people with Ebola and family and friends in close contact with people with Ebola are at the highest risk of getting infected because they may come in direct contact with the blood or body fluids of the sick person. In some places affected by the current outbreak, care may be provided in clinics with limited resources (for example, no running water, no climate control, no floors, and inadequate medical supplies), and workers could be in those areas for several hours with a number of Ebola infected patients.[63]In August, it was reported that healthcare workers have represented nearly 10 percent of the cases and fatalities, significantly impairing the ability to respond to the outbreak in a country which already faces a severe shortage of doctors.[64] In August, the WHO reported that more than 240 health care workers had developed Ebola and more than 120 had died; by 7 September, the cases had risen to 301 with 144 deaths.[65] According to the WHO, the high proportion of infected medical staff can be explained by lack of the number of medical staff needed to manage such a large outbreak, shortages of protective equipment, or improperly using what is available, and “the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe.”.[15]

Comparing the present Ebola outbreak to some in the past, the WHO notes that many of the most recent districts in which epidemics have occurred were in remote areas where the transmission had been easier to track and break. This outbreak is different in that large cities have been affected as well, where tracking has been difficult and medical staff may not suspect Ebola disease when they make a diagnosis. Several infectious diseases endemic to West Africa, such as malaria and typhoid fever, mimic the symptoms of Ebola disease, and doctors and nurses may see no need to take protective measures.[15] Also, without recent past experience with the disease, people have become intensely fearful and have, in some cases, attacked medical staff, believing that they cause the disease.[15]

The WHO reports that in the hardest hit areas there have historically been only one or two doctors available to treat 100,000 people, and these doctors are heavily concentrated in urban areas; the loss of so many health workers has made it difficult for the WHO to provide sufficient numbers of medical staff. Among the fatalities is Samuel Brisbane, a former advisor to the Liberian Ministry of Health and Social Welfare, described as “one of Liberia’s most high-profile doctors.”[66] In July, leading Ebola doctor Sheik Umar Khan from Sierra Leone died in the outbreak. His death was followed by two more deaths in Sierra Leone: Modupe Cole, a senior physician at the country`s main referral facility,[67] and Sahr Rogers, who worked in Kenema.[68][68][69][70] The African Union has launched an urgent initiative to recruit more health care workers from among its members.[15]

Two American health workers that contracted the disease in Liberia and later recovered said that their team of workers had been following “to the letter all of the protocols for safety that were developed by the CDC and WHO”, including a full body coverall, several layers of gloves, and face protection including goggles. One of the two, a physician, had worked with patients, but the other was working to help workers get in and out of their protective gear, while wearing protective gear herself. In an interview she stated, “At this time we have not been able to confirm 100 percent the method of contagion. We are working closely with CDC and WHO to investigate. It is just an incredibly contagious disease.”[71]

Level of care

In late August, Médecins Sans Frontières (MSF) called the situation “chaotic” and the medical response “inadequate”. They report that they have expanded their operations but have been unable to keep up with the rapidly increasing need for assistance which has forced them to reduce the level of care they are able to offer: “It is not currently possible, for example, to administer intravenous treatments.” Calling the situation “an emergency within the emergency”, MSF reports that many hospitals have had to shut down due to lack of staff or fears of the virus among patients and staff which has left people with other health problems without any care at all. Speaking from a remote region, a MSF worker said that a shortage of protective equipment was making the medical management of the disease difficult and that they had limited capacity to safely bury bodies.[78] By September, treatment for Ebola patients had become unavailable in some areas. Speaking on 12 September, WHO director-general Margaret Chan said, “In the three hardest hit countries, Guinea, Liberia and Sierra Leone, the number of new cases is moving far faster than the capacity to manage them in the Ebola-specific treatment centers. Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia.”[18]

Experimental treatments

The unavailability of treatments in the most-affected regions has spurred controversy, with some calling for experimental drugs to be made more widely available in Africa on a humanitarian basis, and others warning that making unproven drugs widely available would be unethical, especially in light of past experimentation conducted in developing countries by Western drug companies.[79][80] As a result of the controversy, an expert panel of the WHO on 12 August endorsed the use of interventions with as-yet-unknown effects both for treatment and for prevention of Ebola, and also said that deciding which treatments should be used and how to distribute them equitably were matters that needed further discussion.[81] Subsequently the WHO assistant director-general for health systems and innovation said on 5 September that transfusion of whole blood or purified serum from Ebola survivors is the therapy with the greatest potential to be implemented immediately on a large scale in West Africa, although there is little information on the efficacy of such treatment.[82] In mid-September the sale of black market blood from survivors of the disease has been noted as a new trend in the Ebola-affected regions. While serum derived blood from surviving victims has been used under strict control in certain cases, this trend in an uncontrolled manner could lead to other infectious diseases. This treatment must be properly implemented as a medical treatment under strict control and screening of possible donors. Margaret Chan of the WHO has criticized the use of this practice in a black market environment, noting concerns over “storage and collection methods”.[83]

A number of experimental treatments are being studied or will undergo trials proximately:[84]

ZMapp, a monoclonal antibody vaccine. The limited supply of the drug has been used to treat a small number of individuals infected with the Ebola virus. Although some of these have recovered the outcome is not considered statistically significant.[85] ZMapp has proved highly effective in a trial involving rhesus macaque monkeys.[86]

Favipiravir, a drug approved in Japan for stockpiling against influenza pandemics.[88] The drug appears to be useful in a mouse model of the disease[89][90] and Japan has offered to supply the drug if requested by the WHO.[91]

The Jenner Institute has announced a first phase I trial of a vaccine targeted at the Zaire strain of Ebola virus that is causing the current outbreak, to commence mid-September.[92]

Prognosis

According to a website for collaborative analysis and discussion about the Ebola emergence, as of 7 August, attempts to create an accurate Case Fatality Rate (CFR) had been unreliable due to differences in testing policies, the inclusion of probable and suspected cases, and primarily the rate of new cases that have not run their course.[93] However, on 28 August, the WHO made their first overall case fatality rate estimate of 52%. It ranges from 42% in Sierra Leone to 66% in Guinea.[94][95] Compared to previous Zaire strain outbreaks, this number is quite low. The twelve Zaire strain outbreaks since the first one reported in the Democratic Republic of Congo in 1976 have had an average CFR of about 76%. Even the Sudan ebolavirus species, known to be less virulent than the Zaire species of the Ebola virus, has had an average CFR of about 57%.[96] However, a weakness of the WHO figures is that they simply divide the number of deaths by the total number of total cases; this will underestimate the CFR as it includes recent diagnoses who may not survive.[8]

Projections

The basic reproduction number is a statistical measure of the number of people who are expected to be infected by one person who has the disease in question. If the rate is less than 1, the infection will die out in the long run. But if the rate is greater than 1 the infection will be able to spread in a population.[97] Using data supplied by the WHO, an August study found that an estimate for this virus was between 1.4 and 1.7 at that time, meaning that each newly infected individual had subsequently infected 1.4 to 1.7 more. The time between initial infection and the infecting of others for this virus is short. The basic reproduction number coupled with a short transfer time for this epidemic is of great concern [98] According to a research paper released in August, in the hypothetical worst-case scenario, if a reproduction number of over 1.0 continues for the remainder of the year we would expect to observe a total of 77,181 to 277,124 additional cases within 2014.[99]

On 28 August, the WHO released its first estimate of the possible total cases (20,000) from the outbreak as part of its roadmap for stopping the transmission of the virus.[100][101] The WHO roadmap states “[t]his Roadmap assumes that in many areas of intense transmission the actual number of cases may be 2 – 4 fold higher than that currently reported. It acknowledges that the aggregate case load of EVD could exceed 20,000 over the course of this emergency. The Roadmap assumes that a rapid escalation of the complementary strategies in intense transmission, resource-constrained areas will allow the comprehensive application of more standard containment strategies within 3 months.”[101] It does not provide details of how it made this total casualty estimate or a more detailed projection of how Ebola casualty statistics might evolve over time. It includes an assumption that some country or countries will pay the required cost of their plan, estimated at half a billion dollars.[101] However, while the WHO has projected a total of 20,000 cases, some of the United States’ leading epidemiologists predict a much higher number. Writing in the NYT on 12 September, Bryan Lewis, an epidemiologist at the Virginia Bioinformatics Institute at Virginia Tech, said that researchers at various universities who have been using computer models to track the growth rate say that at the virus’s present rate of growth, there could easily be close to 20,000 cases in one month, not in nine. [102]

On 3 September, Thomas Kenyon]], Director of the U.S. CDC’s Center for Global Health, said “The highly virulent disease, which has claimed more than 1,900 lives so far, is spreading faster than health workers in Guinea, Liberia, Nigeria and Sierra Leone can manage”.[103] Similar comments were made by Anthony Fauci, Director of [the US] NIH’s National Institute of Allergy and Infectious Diseases, who said that 42 percent of the cases have occurred in the last month and that the outbreak is “completely out of control”. He further noted that the rate of infection is exponential: “The number of cases per unit time is dramatically increasing.”[104] On 8 September, the WHO warned that the number of new cases in Liberia was increasing exponentially, and would increase by “many thousands” in the following 3 weeks.

On 9 September, Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine controversially announced that the containment fight in Sierra Leone and Liberia has already been “lost” and that the disease will “burn itself out” after, eventually, infecting nearly the entire population, with half of them, or around five million deaths.[105]

Epidemiology

Countries with local transmission

Guinea

Researchers believe that the first human case of the Ebola virus disease leading to the 2014 outbreak was a 2-year-old boy who died 6 December 2013 in the village of Meliandou, Guéckédou Prefecture. In early August, Guinea closed its borders with both Sierra Leone and Liberia to help contain the spread of the disease, as more new cases were being reported in those countries than in Guinea.

Thinking that the virus was contained, Médecins Sans Frontières closed its treatment centers in May leaving only a small skeleton staff to handle the Macenta region. However, high numbers of new cases reappeared in the region in late August. According to Marc Poncin, a coordinator for MSF, the new cases are related to persons returning to Guinea from neighbouring Liberia or Sierra Leone.[51]

Liberia

In Liberia, the disease was reported in Lofa and Nimba counties in late March.[106] By 23 July, the Liberian health ministry began to implement measures to improve the country’s response to the outbreak.[107] On 27 July, Ellen Johnson Sirleaf, the Liberian president, announced that Liberia would close its borders, with the exception of a few crossing points, such as the country’s principal airport, where screening centres would be established, and the worst-affected areas in the country would be placed under quarantine.[57]Footballevents were banned, because large gatherings and the nature of the sport increase transmission risks.[108] Three days after the borders were closed, Sirleaf announced the closure of all schools nationwide, including the University of Liberia,[109] and a few communities were to be quarantined.[110] Sirleaf declared a state of emergency on 6 August, partly because the disease’s weakening of the health care system has the potential to reduce the system’s ability to treat routine diseases such as malaria; she noted that the state of emergency might require the “suspensions of certain rights and privileges.”[111] On the same day, the National Elections Commission announced that it would be unable to conduct the scheduled October 2014 senatorial election and requested postponement,[112] one week after the leaders of various opposition parties had publicly taken different sides on the question.[113] On 30 August, Liberia’s Port Authority cancelled all “shore passes” for sailors from ships coming into the country’s four seaports.[114]

On 18 August, a mob of residents from West Point, an impoverished area of Monrovia, descended upon a local Ebola clinic to protest its presence. The protesters turned violent, threatening the caretakers, removing the infected patients, and looting the clinic of its supplies, including blood-stained bed sheets and mattresses. Police and aid workers expressed fear that this would lead to mass infections of Ebola in West Point.[115][116] On 19 August, the Liberian government quarantined the entirety of West Point and issued a curfew state-wide.[117][118] Violence again broke out on 22 August after the military fired on protesting crowds.[119] The quarantine blockade of the West Point area was lifted on 30 August. The Information Minister, Lewis Brown, said that this step was taken to ease efforts to screen, test, and treat residents for the disease.[120]

On 8 September, an offer from U.S. President Barack Obama to provide military support to assist in establishing isolation units and providing security for health workers was accepted by the Liberian government.[121]

Nigeria

The first reported Ebola case in Nigeria was an imported case of a Liberian-American, Patrick Sawyer, who travelled by air from Liberia and became violently ill upon arriving in the city of Lagos. Sawyer died five days later, on 25 July. In response, the Nigerian government observed all of Sawyer’s contacts for signs of infection and increased surveillance at all entry points to the country; health officials were placed at entry points to conduct tests on people arriving in the country.[124] On 19 August, it was reported that the doctor who treated Sawyer, Ameyo Adadevoh, had also died of Ebola disease.[125][126] Adadevoh, a descendant of Herbert Macaulay[127][128] andSamuel Ajayi Crowther[129] was posthumously praised for preventing the index case (Sawyer) from leaving the hospital at the time of diagnosis, thereby playing a key role in curbing the spread of the virus in Nigeria. On 6 August, Nigerian authorities confirmed the Ebola death of a nurse who had also treated Sawyer.[130]

On 19 August, the Commissioner of Health in Lagos announced that Nigeria had seen twelve confirmed cases; four died (including the index case) while another five, including two doctors and a nurse, were declared disease-free and released.[122][132] Other than increased surveillance at the country’s borders, the Nigerian government states that they have also made attempts to control the spread of disease through an improvement in tracking, providing education to avert disinformation and increase accurate information, and the teaching of appropriate hygiene measures: “Efforts are currently ongoing to scale up and strengthen all aspects of response, including contact tracking, public information and community mobilization, case management and infection prevention and control, and coordination. There is now increased disease surveillance system in a bid to monitor, control, and prevent any occurrence of the disease”.[122]

On 22 August, a doctor who treated a Liberian diplomat (Olubukun Koye) in the Mandate Hotel [133]—who had contact with Patrick Sawyer—died in Port Harcourt from Ebola. The BBC report said the diplomat had escaped from quarantine in Lagos and traveled to the city for medical treatment where he survived after being treated. As at the end of August, the total number of deaths from Ebola in Nigeria stood at six. The Good Heart Hospitalwhere the doctor had been admitted before his death and the hotel where he treated the diplomat were shut down. As a result, suspected contacts were subsequently quarantined.[134][135][136] On 11 September, Nigeria announced that it no longer has even a single case of Ebola, but will need to wait for about a week more before declaring itself completely Ebola-free.[137][138]

Sierra Leone

The first person recorded to be infected with Ebola was a tribal healer who had treated an infected person, or persons, in her area and was reported to have died on 26 May. According to tribal tradition, her body was washed for her burial and several women from neighboring towns became infected.[139]

On 1 April, Sierra Leone instituted a temporary measure which included reactivation of its “Active Surveillance Protocol” that would see all travellers into the country from either Guinea or Liberia subjected to strict screening to ascertain their state of health.[140] The government of Sierra Leone declared a state of emergency on 30 July and deployed troops to quarantine the hot spots of the epidemic.[141]

On 29 July, well-known physician Sheik Umar Khan, Sierra Leone’s only expert on hemorrhagic fever, died after contacting Ebola at his clinic in Kenema. Khan had long worked with Lassa fever, which kills over 5,000 a year in Africa, and had expanded his clinic to accept Ebola patients when the disease broke out. At his death, Sierra Leone President Ernest Bai Koroma celebrated Khan as a “national hero”.[139]

In August, awareness campaigns in Freetown, Sierra Leone’s capital, were delivered over the radio or through car loudspeakers.[142] Also in August, Sierra Leone passed a law that will subject a two-year jail term on anyone found to be hiding a person who is believed to be infected with Ebola disease. The new measure was announced as a top parliamentarian lashed out at neighbouring countries for failing to do more to curtail the outbreak.[143]

On 26 August, the WHO said it had shut down one of its two laboratories in Sierra Leone after a health worker there was infected with Ebola. The laboratory is situated in the Kailahun district, one of the worst affected areas in Sierra Leone. This may disrupt efforts to increase the global response to the outbreak of the disease in the district.[144] “It’s a temporary measure to take care of the welfare of our remaining workers,” WHO spokesperson Christy Feig announced. He did not specify how long the closure would last, but they will return after the WHO assessment of the situation. The medical worker is one of the first WHO staff infected by the Ebola Virus. The worker was first treated at a government hospital in Kenema and then evacuated to Germany for further treatment.[144][145]

Senegal

In March, the Senegal Ministry of Interior ordered all movements of people through the southern border with Guinea to be suspended indefinitely to prevent the spread of the disease, according to a statement published on 29 March by state agency APS.[146]

On 29 August, the Senegalese Health minister, Awa Marie Coll Seck, announced the first case of Ebola in the country. The patient arrived from the neighbouring country Guinea, where the virus was first reported. The case has been confirmed in Senegal.[37][38] The patient, a university student from Guinea, is being treated in Dakar. Samples were sent to the Institut Pasteur, where Ebola was confirmed. The WHO was informed of the situation on 30 August [147] and is treating the situation “as a top priority emergency”, and it has now dispatched operational personnel to Dakar.[148]

India

On 27 August, a Health Ministry official said that 112 Indian citizens and four Nepalese citizens had landed in Mumbai and Delhi from Liberia.[149] Of the 17 who had arrived in Delhi, one had fever symptoms and had been quarantined at the Airport Health Organisation (APHO), an airport medical facility. Six others were screened for Ebola, and five passengers who arrived on routine flights from affected countries showing fever symptoms had also been quarantined. Earlier, it was reported that an isolation facility with 120 beds was being created in the Hindu Hriday Samrat Jogeshwari trauma care hospital by Brihanmumbai Municipal Corporation (BMC).[150] On 28 August, the Health Ministry reported that 821 people were being monitored and tracked for the Ebola virus.[151]

Spain

On 5 August, the Brothers Hospitallers of St. John of God confirmed that the Spanish Brother Miguel Pajares was infected with the Ebola virus while volunteering in Liberia. His repatriation, coordinated by the Spanish Ministry of Defence, occurred on 6 August 2014.[152]Spanish authorities confirmed that the patient would be treated in the ‘Carlos III’ hospital in Madrid. The decision attracted some controversy, amid questions as to the authorities’ ability to guarantee no risk of transmission.[153] Brother Pajares died from the virus on 12 August.[154]

United Kingdom

In August, an isolation unit at the Royal Free Hospital in North London was prepared to treat patients with highly infectious diseases. On 24 August, William Pooley, a British citizen, was medically evacuated from Sierra Leone for treatment in the newly created unit. Pooley, a British health worker, is the first British citizen confirmed to have contracted the disease in Sierra Leone.[155] On 3 September, the 29-year old Pooley was discharged from hospital after a making full recovery from the disease.[156]

United States

American aid worker Kent Brantly, a physician, became infected with Ebola, while working in a Monrovia treatment centre as medical director for the aid group Samaritan’s Purse; Nancy Writebol, one of Brantly’s missionary co-workers, became infected at the same time.[71][157][158] Both were flown to the United States at the beginning of August for further treatment in Atlanta‘s Emory University Hospital, near the headquarters of the Centers for Disease Control.[159] On 21 August, both Brantly and Writebol were discharged from Emory University Hospital, having recovered from the virus.[160]

On 4 September, a Boston physician, Rick Sacra, was airlifted from Liberia to be treated in the United States. He is the third US missionary, working for Serving In Mission (SIM), who has tested positive for the disease. Sacra is being treated in Omaha at the Nebraska Medical Center.[161] The doctor did not get infected while treating Ebola patients, but was exposed to the virus while delivering babies at a hospital in Liberia.[162] On 9 September, it was reported that Sacra is receiving an experimental therapy (not ZMapp) and it was later announced that he had received a blood transfusion from Kent Brantly, an American physician who has recovered from the disease. It has been theorized that transfusing blood products from former Ebola patients may assist a diseased person’s immune system to fight the disease. As of 11 September, he has shown “remarkable” improvement though recovery remains uncertain.[163][164]

On 9 September, the fourth U.S. citizen who contracted the Ebola virus arrived at Emory University Hospital in Atlanta for treatment. The patient was airlifted from Sierra Leone and landed at Dobbins Air Reserve Base. The identity of the patient, a male doctor working for the WHO in Sierra Leone, has not been released. According to doctors at the hospital, he will not be receiving any experimental treatment and will only receive supportive care to boost his immune system. The patient exited the ambulance and was assisted into the hospital while walking on his own.[165]

Timeline

A timeline of the outbreak follows, using data reported by the Centers for Disease Control and Prevention[166] and the WHO.[167] The table also includes suspected cases that have yet to be confirmed for the virus. The reports are sourced from official information from the affected countries’ health ministries. WHO has stated the reported numbers “vastly underestimate the magnitude of the outbreak”.[168] Cases in remote areas may also be missed.[169]

Note that numbers for cases and deaths are in constant flux. Numbers reported for cases may include probable or suspected cases; numbers are revised downward if a suspected case turns out to be negative.

Date is the “as of” date from the reference. A single source may report statistics for multiple “as of” dates.

Total cases and deaths before 1 July 2014 are calculated.

Numbers with ± are deltas from a previous report. The deltas may not be consistent.

Numbers with a ↓ indicate cases that were eliminated.

Liberia:

29 Mar: LI data is confused. Earlier, there were 8 suspected cases and 6 deaths (no confirmed cases). Seven suspected cases were tested by 29 Mar, and five were not Ebola. That should take suspected cases to 3, but a total was not stated; it also implies deaths should be at most 3. The report states only 2 suspected deaths were tested, and one was not Ebola.[224]

21 Apr: reduced deaths by 2: one in Guinea total and one case discarded. 26 samples negative for Ebola.[214]

24 Apr: stated it was reviewing its 27 suspected cases and may toss all of them;[213]

Democratic Republic of Congo

On 20 August, several people, including four health care workers, were reported to have died of Ebola-like symptoms in the remote northern Équateur province, a province that lies about 750 miles north of the capitalKinshasa.[232] By 21 August, 13 people were reported to have died with similar symptoms. On 26 August, the Équateur Province Ministry of Health confirmed an outbreak of Ebola to the WHO.[233] The initial case was a woman from Ikanamongo Village who became ill with symptoms of Ebola after she had butchered a bush animal that her husband had killed. She was treated in a private clinic, but on 11 August she died of a then-unidentifiedhemorrhagic fever. The following week relatives of the woman, several health-care workers who had treated the woman, and individuals that they had been in contact with came down with similar symptoms. Five health care workers subsequently died.[233]

On 26 August, the WHO reported that between 28 July and 18 August a total of 24 suspected cases of Ebola virus disease, including 13 deaths, had been reported. The index case and the 80 contacts had no history of travel to the Ebola-affected countries or history of contact with individuals from the affected areas, and it was believed that the outbreak in DRC was unrelated to the ongoing outbreak in West Africa.[233]

On 2 September, the WHO said that there were currently 31 deaths in the Northern Boende area in the province of Équateur and 53 confirmed, suspected or likely cases.[231] The WHO confirmed that the current strain of the virus in the Boende District is the Zaire Ebola species. This strain is common in the country and similar to the 1995 Kikwit outbreak in the Democratic Republic of Congo. The virology results and epidemiological findings indicated no connection to the current epidemic in West Africa Region or Nigeria.[234]

On 9 September, the WHO raised the number of cases to 62 and the death toll to 35 from possible or confirmed Ebola cases. Included in this number are 9 health-care workers with 7 deaths among them. In total 386 contacts have been listed and 239 contacts are being followed up. The outbreak is still contained in Jeera county in the Boende region.[6]

Economic effects

In addition to the loss of life, the outbreak is having a number of significant economic impacts.

Markets and shops are closing, due to travel restrictions, cordon sanitaire, or fear of human contact, leading to loss of income for producers and traders.[235]

Movement of people away from affected areas has disturbed agricultural activities.[236][237]

Tourism is directly impacted in affected countries.[238] Other countries in Africa which are not directly affected by the virus have also reported adverse effects on tourism.[239]

The IMF is considering expanding assistance to Guinea, Sierra Leone, and Liberia as their national deficits balloon and their economies contract sharply. [247]

Responses

World Health Organization

The World Health Organization‘s (WHO) Regional Director for Africa, Luis Sambo, visited the affected countries from 21 to 25 July, meeting with political leaders, ministers of health, NGOs, and other agencies. He stressed the need to “promote behavioural change while respecting cultural practices.”[34] On 24 July, WHO’s Director General met with agencies and donors in Geneva to facilitate an increase in funding and manpower to respond to the outbreak.[34]

WHO declared the outbreak an international public health emergency on 8 August, after a two-day teleconference of experts.[45] On 11 August, they emphasised lack of supplies and capacity as one of the problems, while local awareness of the disease had increased.[248] Revised guidelines on how to prevent the spread of the disease were released, updating guidelines from 2008.[249]

On 28 August, the WHO said it is seeking $490 million in funding to fight the outbreak.[250] They report that they “are on the ground establishing Ebola treatment centres and strengthening capacity for laboratory testing, contact tracing, social mobilization, safe burials, and non-Ebola health care” and “continue to monitor for reports of rumoured or suspected cases from countries around the world.” Other than cases where individuals are suspected or have been confirmed of being infected with Ebola, or have had contact with cases of Ebola, the WHO does not recommend any travel or trade restrictions.[15]

On 16 September WHO Assistant Director General, Bruce Aylward, announced that the cost for combating this disease epidemic will spiral to a staggering $1 billion. “We don’t know where the numbers are going on this,” according to Aylward. In addition aid workers have predicted an “explosive” increase in new case numbers in the following days in the epidemic area.[251]

US Centers for Disease Control

On 31 July, US health officials from the US Centers for Disease Control (CDC) issued a travel advisory for Guinea, Liberia, and Sierra Leone, warning against non-essential travel.[252] By 26 August, the CDC had issued a Level 3 travel warning for Sierra Leone, Guinea, and Liberia and a Level 2 travel warning for Nigeria.[253] The Level 3 warning is the highest that can be issued and will be in place until 27 February 2015. It means that United States residents must avoid nonessential travel to the three countries worst hit by the virus.

By the beginning of August, the US Centers for Disease Control had placed staff in Guinea, Sierra Leone, Liberia, and Nigeria to assist the local Ministries of Health and WHO-led response to the outbreak.[122] On 6 August, the Centers for Disease Control moved its Ebola response to Level 1 (the highest on a scale from 1 to 6) to increase the agency’s ability to respond to the outbreak.[254]

Médecins Sans Frontières

The humanitarian aid organisation Médecins Sans Frontières (Doctors Without Borders) started its Ebola intervention in West Africa in March 2014 and is now present in Guinea, Liberia, Nigeria, and Sierra Leone. By the end of August, the organization ran five Ebola case management centers with a total capacity of 415 beds. Since March, MSF has admitted a total of 1,885 patients. Of these patients 907 tested positive for Ebola and 170 recovered. MSF has deployed 184 international staff to the region and employs 1,800 nationally hired personnel.[78] On 29 August MSF described the international response as slow and derisory.[256]

Samaritan’s Purse

Samaritan’s Purse is also providing direct patient care in multiple locations in Liberia.[257] At a congressional committee hearing on 7 August 2014, the head of Samaritan’s Purse stated that “The disease is uncontained and out of control in West Africa.”[258]

World Food Program

On 18 August, World Food Program announced plans to mobilise food assistance for an estimated 1 million people living in restricted access areas.[259]

World Bank Group

The World Bank Group has pledged up to US $200 million in emergency funding to help Guinea, Liberia, and Sierra Leone contain the spread of Ebola infections, help their communities cope with the economic impact of the crisis, and improve public health systems throughout West Africa.[244]

Response by countries

Australia

On 14 August, the Australian ambassador to the People’s Republic of China revealed that the Australian government would donate US$1 million to the World Health Organization, in addition to its annual support, to assist in combating the Ebola outbreak.[260]

Brazil

Brazil has donated three kits to Guinea, five to Sierra Leone and five more to Liberia. They are waiting for the United Nations to indicate how and when to ship. Each kit can handle up to 500 people for three months which contains gloves, hats, saline and more.[261]

Canada

On 12 August, the Public Health Agency of Canada (PHAC) announced that the country would donate between 800 and 1,000 doses of an untested vaccine (VSV-EBOV) to the WHO.[262] The offer was made by the Minister of Health directly to the Director General of the WHO as part of the country’s commitment to containment efforts. The Government of Canada holds the intellectual property associated with the vaccine, but has licensed BioProtection Systems of Ames, Iowa to develop the product for use in humans.[263]

As of 12 August, Canada’s contribution to address the spread of the Ebola virus in West Africa is estimated at $5,195,000. This includes resources dedicated to humanitarian, security, and public health interventions.[264]

On 26 August, the PHAC said it is preparing to bring home three members from their mobile laboratory in Sierra Leone. The three Canadians were among six workers at the mobile lab. The team is from the National Microbiology Laboratory in Winnipeg. The recall follows the diagnoses of three persons, staying at the same hotel as the team members, with the Ebola virus. The team members had no direct contact with the infected persons and are not showing any signs of the disease. The team members will be monitored as they travel back to Canada and will remain in voluntary isolation until cleared, officials from the PHAC said.[265]

On 6 September, the Public Health Agency of Canada announced that they will be resuming work at the Kailahun mobile laboratory after recalling them in late August for safety reasons. A three person team have been sent to the laboratory in eastern Sierra Leone. The team will rotate on a monthly basis.[266]

Chad

The Prime Minister of Chad, Kalzeubet Pahimi Deubet, said it will follow in the footsteps of South Africa and impose travel restrictions to and from the countries currently affected by the Ebola outbreak. Chad will close all its borders to Nigeria to prevent the spread of the disease to the country. He added that this would have an economic impact to Chad and the region, but the restrictions are necessary.[267]

China

A Chinese plane carrying supplies worth 30 million yuan (4.9 million US dollars) arrived in Guinea, Sierra Leone, and Liberia on 11 August.[268][269] This is their second Ebola relief after the first batch delivered in May to Guinea, Liberia, Sierra Leone, and Guinea-Bissau. The supplies include medical protective clothes, disinfectants, thermo-detectors, and medicines. China also sent three expert teams composed of epidemiologists and specialists in disinfection and protection as well as medical supplies to Guinea, Liberia, and Sierra Leone despite high risk of infection.[270][271] Before their arrival, eight members of a Chinese medical team sent to assist patients in Sierra Leone’s hospitals were quarantined after treating Ebola patients.

Some Chinese companies in West Africa also joined the relief efforts. China Kingho Group, a leading exploration and mining company in Sierra Leone, donated 400 million Leones (about $90,000) to the Government and People of Sierra Leone on 15 August.[272]

On 16 August, Chinese President Xi Jinping and UN Secretary-GeneralBan Ki-moon on Saturday discussed several hot issues, including Ebola, in their fourth meeting this year. The meeting in Nanjing, capital of east China’s Jiangsu Province, was held before they attended the opening ceremony of the 2nd Summer Youth Olympic Games. Xi said China will continue to make joint efforts with the international community to prevent and control the Ebola virus outbreak that has hit West Africa. China has provided emergency medical assistance to Ebola-hit countries and sent expert groups. China’s medical teams in the countries are working with local staff, according to Xi. Xi also spoke highly of the measures taken by the United Nations and WHO and its professional institutions, and called for more assistance and input for medical and health services in African countries.[273]

Colombia

On 8 August, the Vice Minister of Health and Social Protection of Colombia, Fernando Ruiz, assured the public that the Government is preparing itself to face the virus even though Colombia’s given conditions don’t give Ebola the chance to natively spread since “the bat species in charge of transmitting the disease nor the practice of eating it aren’t present in Colombia.”[274] Ruiz also stated that Colombians travelling to the affected parts of West Africa are being warned to take appropriate precautions.[275] Previously, on 5 August, the Ministry of Health and Social Protection issued a press release stating that “since the month of April the National Government has been closely following and monitoring the outbreak of the Ebola virus in West Africa and the State has decided to adopt word by word the contingency plan prepared by the WHO.”[276]

Cuba

On 10 September, Cuba announced its willingness to help curtail the spread of the disease. Cuba will be sending 165 doctors and nurses to Sierra Leone on a six month rotation starting early October. Infection control specialists will be among the group.[277]

Equatorial Guinea

Germany

Germany’s Foreign Office issued travel warnings for all affected countries at the end of July,[279] Spain did so on 2 August[280] and the UK did on 20 August.[281]

Ghana

On 30 August, the Ghanaian Presidency released a press statement, announcing the country’s willingness to use Accra as a support base to help fight Ebola in the stricken countries. This agreement follows a telephonic meeting with the United Nations chief, Ban Ki-moonand John Dramani Mahama, the President of Ghana. Accra will serve as a base for air lifting medical and other supplies to countries affected by the Ebola outbreak, as well as personnel to curtail the disease.[282]

India

On 8 August, India placed all of its airports on high alert and stepped up surveillance of all travellers entering the country from Ebola-affected regions. The Union Health Minister, Harsh Vardhan, issued a statement, “There is no cause for panic. We have put in operation the most advanced surveillance and tracking systems.” From 9 August, passengers coming from Ebola-affected countries will have to complete a form before landing; the form has a check-list for symptoms and asks travellers from West Africa for information about places visited, length of stay and other important information.

“The form is ready and will be officially released by Saturday. We will request all airlines to direct their staff to distribute the form in-flight, like immigration forms are given before arrival,” said Jagdish Prasad, director general of health services, Union Ministry of Health. In New Delhi, Ram Manohar Lohia Hospital in New Delhi has been designated as a treatment centre for Ebola Virus Disease (EVD) cases. A 24-hour emergency helpline will also be functional from Saturday. Its numbers are (011)-23061469, 3205 and 1302. The estimated 47,000 Indians in the affected countries are being contacted by area diplomatic missions and supplied with educational material about the disease.[283]

Ivory Coast

The Ivory Coast, on 22 August, released a statement on state-owned television announcing the closure of its borders to the neighbouring countries affected by the Ebola outbreak. Attempting to prevent the Ebola outbreak of the virus from spreading to the Ivory Coast, the government announced the closure of all its land based borders to the country’s West African neighbours Guinea and Liberia.[284]

The Ivory Coast previously placed a ban on all flights to and from Sierra Leone, Liberia, and Guinea.[285] Côte d’Ivoire (Ivory Coast) is allowing shipping commerce to enter the port of Abidjan from the affected countries of Guinea, Sierra Leone and Liberia. Vessels coming from those countries are required to undergo a medical inspection by a boarding team prior to entry.[286]

Japan

In April, the Government of Japan gave $520,000 through the United Nations Children’s Fund (UNICEF) to support the Ebola outbreak response in Guinea.[287] In August, another $1.5 million in additional support was provided to be disbursed via the WHO, UNICEF andRed Cross, and will be used for measures to prevent Ebola infections and to provide medical supplies.[288]

On 25 August, Japanese authorities announced that they would be willing to provide access to an anti-influenza drug currently under development called favipiravir to try to treat EVD patients.[289] Fujifilm Holdings Corp and MediVector have reportedly approached the U.S. Food and Drug Administration to request approval for this experimental use of favipiravir. Up to 20,000 doses of favipiravir would currently be available.

Kenya

The Kenyan government banned people travelling from or through Sierra Leone, Guinea, and Liberia for all ports of entry.[290]

Malaysia

Malaysia plans to send more than 20 million medical gloves to Guinea, Liberia, Nigeria and Sierra Leone to alleviate a shortage of medical supplies in the affected countries. Malaysia will also send medical gloves to the Democratic Republic of Congo which is also dealing with an Ebola outbreak unrelated to the one affecting West Africa.[291]

Morocco

Beginning in April, Morocco reinforced medical surveillance at the Casablanca airport, a regional hub for flights from and to West Africa.[292][293] In early August, Liberian interior minister Morris Dukuly announced the Ebola death of a Liberian man in the country,[294] but the Moroccan Ministry of Health announced that the person died of a heart attack, rather than Ebola.[295]

Philippines

The Philippine Department of Foreign Affairs has raised Alert Level 2 in Guinea, Liberia, and Sierra Leone and has temporarily halted the sending of Filipino workers to the affected countries since 30 June. Filipino seafarers are also cautioned about potentially contracting Ebola when their ships dock in affected countries.[296] The Department of Health expressed its willingness to send medical workers to Ebola-affected countries to help contain the outbreak.[297] On 23 August, the Philippines announced that it is pulling out its 115 UN peacekeepers stationed in Liberia due to the increasing health risk the troops face due to the outbreak.[298]

Qatar

Qatar has banned the import of live animals, food and meat products from Guinea, Liberia, Sierra Leone, and Nigeria as a precaution against Ebola.[299]

Seychelles

Seychelles introduced a visa requirement for the citizens of Sierra Leone, Liberia, Guinea-Bissau, Guinea Conakry, Nigeria, Cameroon, Chad, Niger, Burkina Faso, Mali, Benin, Ivory Coast, Ghana, Togo, Congo, D.R. Congo, Gambia, Mauritania, and Senegal. Citizens of these countries will require a visa until the Ebola outbreak is declared over.[300] Members of the Sierra Leone national football team were refused visas over the outbreak.[301]

Saudi Arabia

On 5 August, Saudi Arabia announced that it would block issuance of Hajj and Umrah visas to the citizens of Sierra Leone, Guinea, and Liberia.[303]

On 6 August, the Saudi Ministry of Health advised citizens and residents of Saudi Arabia to avoid travelling to Liberia, Sierra Leone, and Guinea until further notice.[304]

South Africa

On 21 August, South Africa announced a ban on all travelers from the three Ebola-hit West African nations. A government spokesman confirmed they are following other countries responses to the disease outbreak. The health ministry of South Africa confirmed that the country’s citizens would be asked to limit travel to absolutely essential needs, if going to the countries involved in the current outbreak. All South Africans returning from these countries would only be allowed back after undergoing extensive medical tests, and quarantine, if necessary.[305]

Sri Lanka

United Kingdom

The UK government has made £2 million available to partners including the International Federation of the Red Cross (IFRC) and Médecins Sans Frontières that are operating in Sierra Leone and Liberia to tackle the outbreak.[307] Additionally a £6.5 million rapid response research initiative has been announced jointly by the Department for International Development and the Wellcome Trust to better inform the management of Ebola outbreaks. This includes research which could help tackle the current outbreak.[308]

On 26 August, British Airways extended its ban on flights to Liberia and Sierra Leone until 31 December due to the declining public health situation.[309][310]

The Foreign Office issued updated travel advice in the week ending 24 August urging Britons to evaluate the need to travel to Sierra Leone, Guinea and Liberia.[155]

On 8 September Mark Francois, a spokesperson for the Minister of Armed Forces, announced that British troops, medics and equipment will be deployed to help assist Sierra Leone in the containing of the disease. An initial survey team consisting of military engineers will be sent to the country within the next couple of days. The troops will be building a 62 bed treatment facility near Freetown. The Armed Forces’ engineers and medics expect the facility to be completed and operational in two months. The treatment center will be staffed by Armed Forces’ medical personnel and handed over to one of the aid organization in the country.[311]

United States

On 8 September, the United States President, Barack Obama, announced that the U.S. will send US military personnel to the epidemic area. The military will be deployed to assist in the setting up of isolation units and provide additional safety to health workers in the area. The US military will also assist in proving and transportation of medical equipment. President Obama added that the steps are necessary to curtail the spread of the virus. This announcement comes amid fears that the virus might mutate and become more virulent and “represents a serious national security concern.”[312]

In an unprecedented move, it is expected that US President Barack Obama will sent 3,000 additional military personnel to the area in an effort to expand the US involvement in combating the spread of the disease. The total cost of this operation is expected to be $500 million. The funding for this massive response will be allocated from the US Department of Defense’s existing budget, from other efforts including the war on Afghanistan. This announcement is likely to be issued on 16 September, according to a spokesperson for the US government.[315]

Economic Community of West African States

On 30 March, during the 44th Summit of the heads of state and government of West Africa, Economic Community of West African States (ECOWAS) disbursed US$250,000 to deal with the outbreak.[316] At the event in July 2014, the Nigerian government donated US$500,000 to the Liberian government to aid the fight against the virus.[317]

In July, the WHO convened an emergency sub-regional meeting with health ministers from eleven countries in Accra, Ghana.[318] On 3 July, the West African states announced collaboration on a new strategy, and the creation of a WHO sub-regional centre in Guinea “to co-ordinate technical support”;[319] the centre was inaugurated in Conakry on 24 July.[320]

On 31 July, the WHO and West Africa nations announced $100 million in aid to help contain the disease.[321]

European Union

In March, the European Commission (EC) gave €500,000 to help contain the spread of the virus in Guinea and its neighbouring countries. The EC has also sent a health expert to Guinea to help assess the situation and liaise with the local authorities. EU Commissioner for International Cooperation, Humanitarian Aid and Crisis Response Kristalina Georgieva said: “We are deeply concerned about the spread of this virulent disease and our support will help ensure immediate health assistance to those affected by it. It’s vital that we act swiftly to prevent the outbreak from spreading, particularly to neighbouring countries.”[322]

In April, a mobile laboratory, capable of performing the molecular diagnosis of viral pathogens of risk groups 3 and 4, was deployed in Guinea by the European Mobile Laboratory project (EMLab) as part of the WHO/GOARN outbreak response. Prior samples were analyzed at the Jean Mérieux BSL-4 Laboratory in Lyon.[323]

Bill & Melinda Gates Foundation

On 10 September, the Bill & Melinda Gates Foundation released $50 million to the United Nations and other international aid agencies fighting the epidemic. The foundation also donated $2 million to the CDC to assist them with their burden. The funds were released with immediate effect. Previous donations consisted of $5 million to the WHO and $5 million to UNICEF to buy medical supplies and fund support efforts in the region. This brings the Seattle-based Foundation’s total contribution to date over $60 million. “We are working urgently with our partners to identify the most effective ways to help them save lives now and stop transmission of this deadly disease,” the Foundation CEO said in a statement.[324]

Paul G. Allen Family Foundation

On 11 September, the Paul G. Allen Family Foundation, following the footsteps of the Bill & Melinda Gates Foundation, pledged $9 million to the CDC. The funds will be appropriated to build treatment co-ordination centers and assist in training programs. This follows their earlier donation of $2.8 million, in August, to the Red Cross.[325]

Private donations

Aliko Dangote

On 14 August, the Nigerian government said Aliko Dangote had donated 150 million naira to halt the spread of the Ebola virus outbreak.[326]